His family were very concerned by the fact he was spitting out blood and finding it very difficult to swallow, as a result of biting his tongue.

Despite the A&E co-ordinator being alerted to these concerns, no action was taken until W began to inhale his own vomit, causing his oxygen levels and GCS to plummet.

Despite urgent intervention by the anaesthetic team, W suffered a cardiac arrest and brain ischaemia. He was transferred to a neurosurgical unit but was declared brain stem dead and died.

Suzanne White, a partner in Leigh Day’s clinical negligence team, was instructed to represent Mr W’s family at the inquest into his death.

The Coroner obtained expert evidence and found that the poor care provided to W was as a result of a number of systemic failures. Following W’s death a further 10 specialist nurses were employed by the Trust, and the number of consultants was increased from six to 14.

However, despite the Coroner’s findings, the Trust did not make a full admission of liability until each party’s medical experts met for a joint meeting.

It was agreed by the experts that given W’s condition and the nature of his injury, he should have undergone a CT scan in line with the Emergency Department protocol.

In preparation for the CT scan he would have been intubated and eventually would have made a full recovery. The failure to act in line with the protocol was found to have caused W’s tragic and untimely death.

Following this meeting, which did not take place until some years after W’s death, the Trust settled out of court.

Suzanne White said:

“This is a desperately sad case, where a young man with a severe head injury attended A&E but the extent of his injury was not recognised, one of the reasons being as a result of the shortage of staff.

“The Coroner’s findings speak for themselves, and the fact the Trust had to employ so many staff after W’s death is an illustration of the extent that a shortfall of staff can have a devastating effect on the provision of appropriate care to patients.”